Author: Anthony Sanfilippo
It Takes a Village: Thanks to all involved in our Medical School Admission process
Over two weekends in March, over 500 applicants are invited to our school to undertake interviews, the final phase of our medical school admission process. They have been selected from over 5,000 who submitted applications.
That process, designed by our Admissions Committee, is the product of much thought and deliberation, with the goal of fairly and objectively matching the aspirations and attributes of applicants to those required to assure success not only in medical school, but in the practice of medicine and service of patients.
The process is a massive undertaking, requiring the participation of no fewer than 179 of our faculty and virtually all members of our first- and second-year classes. In fact, our admission process is the most resource intensive activity undertaken by our school.
Each year, I’m amazed and grateful for the willingness of our faculty and students to give of their time and energy for this purpose. File reviews and interviews are both carried out after regular work hours and on weekends, requiring sacrifice of precious personal time. Why do they do it? They recognize, I believe, that this admission process is critical not only to our success as a school, but for the future well-being of our profession and the society we serve.
Our applicants are also impressed. They consistently comment on the effort, which brings credit to our school and demonstrates a learning environment where faculty and students work together in mutual dedication to our school and profession.
I would like to recognize and extend sincere thanks to all the faculty members involved, who will be listed below. The numbers indicate those who filled multiple assignments. I’d like to particularly note the contributions of Drs. Fred Watkins and Mariana Silva, who were both involved in all aspects of both the File Review and Interview process.
I’d also like to thank our first- and second- year classes. I’d initially thought about listing them as well, but quickly realized that was unnecessary since there was essentially no one to exclude! Their presence and support of applicants speaks volumes about their support of our school, and confirms to me that the process is working well. Special thanks to first year president and vice-president Andriy Katyukha and Victoria-Lee Kim who organized their class events and made no fewer than eight presentations to applicants.
Finally, I’d like to recognize three individuals who deserve particular recognition, our Assistant Dean of Admissions, Dr. Hugh MacDonald, Admission Officer Rebecca Jozsa, and Admissions Assistant Rachel Bauder. They oversee a very complex process that ran flawlessly.
Faculty Members Involved in the Admission Process
Amy Acker (2)
Sussan Askari (2)
Allan Baer (2)
Lysa Boisse Lomax
Mark Bona (2)
Rozita Borici-Mazi (2)
J. Gordon Boyd
Cheryl Cline (3)
Ken Collins (2)
Robert Connelly (3)
Christine D’Arsigny (2)
Alexandra Di Lazzaro
Jennifer Flemming (3)
Kan Frederick (2)
Tom Gonder (2)
Mike Green (2)
Richard Gregg (3)
Andrea Grin (2)
Dianne Groll (3)
Andrea Guerin (2)
Karen Hall Barber (2)
Marisa Horniachek (4)
Robyn Houlden (3)
David Hurlbut (4)
Felicia Iftene (2)
Omar Islam (4)
Mala Joneja (2)
Cherie Jones-Hiscock (4)
Sarosh Khalid-Khan (3)
Faiza Khurshid (2)
Alenia Kysela (3)
Kirk Leifso (3)
Athen Macdonald (2)
Gillian MacLean (3)
Paul Manley (2)
Sarah McKnight (2)
Stephen McNevin (2)
Alex Menard (2)
Anne Moffat (5)
Benvon Moran (2)
Raveen Pal (2)
Stephen Pang (2)
Armita Rahmani (2)
Benjamin Ritsma (2)
David Ruggles (3)
M. Khaled Shamseddin (2)
Mariana Silva (9)
Marco Sivilotti (2)
Yi Ning Strube
Rob Tanzola (2)
Naji Touma (2)
Jessica Trier (3)
Todd Urton (3)
Janet van Vlymen
Maria Velez (2)
Ashley Waddington (3)
Ami Wang (4)
Fred Watkins (9)
Shayna Watson (2)
Hasitha Welihinda (2)
Gavin Wood (3)
David Yen (3)
Failure to Thrive in Medical School Syndrome: Signs, Symptoms and Diagnostic Approach
“Failure to Thrive” is a term well-established in the world of clinical medicine. In the pediatric context, it refers to a child who is failing to achieve anticipated developmental milestones. In the adult world, it’s more informally used to describe someone who is simply not doing well in their current circumstances, be it in hospital or in their community setting. Examples would be an elderly patient at home who is slowly declining and losing ability for independent living, or a hospital in-patient who is not improving despite what seems to be appropriate treatment.
The concept, I’ve come to appreciate, can also be usefully applied in the context of medical education. Failure to Thrive in Medical School Syndrome (FTMSS), can be engaged as we would any clinical condition, with characteristic signs and symptoms.
There are six key cardinal signs or manifestations of FTMSS. These include:
- Poor academic performance.
- Absenteeism, or habitual lateness for scheduled events.
- Habitual failure to meet established deadlines for submission of academic reports or administrative requirements.
- Inter-personal conflicts with peers, administrative staff or faculty.
- Poor or unprofessional behaviour in the academic or clinical setting.
- Lack of attention to surroundings, or personal appearance.
Symptoms of the FTMSS sufferer might include lethargy, fragile confidence, diminished sense of self-worth, agitation, defensiveness, anxiety.
As with the approach to any medical syndrome, the objective is not simply to make a diagnosis, but to establish the underlying cause. Understanding the mechanism by which this syndrome develops is essential to helping the sufferer deal with the affliction, establishing appropriate treatment, and hopefully starting down the road to cure.
All the manifestations of FTMSS have the common feature of not being attributable to any intrinsic limitation on the part of the afflicted individual. Having come through the intensely competitive medical school admission process, it seems reasonable to assume that every medical student is fundamentally capable of performing academically, being on time, meeting deadlines, relating reasonably well to others, attending to their personal appearance and behaving professionally. Failure to do any of these things can therefore can reasonably be attributed to some external cause.
And so, what are the root causes of FTTMS? At this point, a disclaimer seems appropriate. In the absence of any tested and proven pathophysiological mechanism for the condition, I provide postulates based on many years of observation of afflicted individuals, perhaps as a basis for clinical management and hypotheses for future clinical trials. That being said, and in no particular order, here goes:
- Failure to adjust to medical education. The medical school curriculum, learning methods and, importantly, the use of assessment in medical school can vary considerably from many other undergraduate programs. Fundamentally, the goals of education are no longer strictly about the aspirations of the learner, but rather geared to preparation to meet the needs of future patients. This change in focus can be somewhat unsettling for some. Moreover, the curriculum can be intense and demanding. Educational methods include much small-group and collaborative activities, as well as required independent learning. Assessments can be frequent and geared not towards short term retention and determining comparisons with other learners, but in assessing individual achievement with respect to learning objectives. In medical school, students therefore find themselves confronted with a learning environment very different than that which they’ve experienced previously. They are also asked to established individual rather than comparative goals of achievement. All this adjustment can be difficult for the student who is accustomed to learning situations which are individual, easily self-controlled and targeted to parameters of external validation.
- Lack of motivation for a career in Medicine. For many students, the decision to engage the medical school application process begins at a very early age. The process can be all-consuming and require the applicant to forgo many opportunities and experiences usually undertaken in childhood and adolescence in order to undertake educational programs and volunteer activities that they, and perhaps their parents, feel relevant to their application. The decision to pursue a career in medicine can therefore prevent a young person from engaging valuable developmental experiences or from considering other interests and potential career options. Others may enter medical school with an incomplete understanding of a medical career. As they understand more clearly what doctors actually do and what is expected of them, they may begin to realize the career is not for them. Medical education and, more importantly, a career in medicine, are both rewarding and demanding. Both require deep commitment.
- Unresolved personal issues. Medical students, like all young people, experience a variety of personal stresses and adversities. There can be a reluctance to recognize or to admit to the full impact of such stresses and to seek help. There can be a concern that admitting that one is feeling challenged or overcome by such circumstances might be seen as signs of internal weakness or unsuitability for their chosen career. There can also be a tendency to defer feelings of loss, disappointment or grief. Over time such unresolved stresses can mount and express themselves in negative ways which may lead to the various manifestations of FTTMS.
- Medical students can become ill or simply run down. Many medical conditions can be gradual, subtle and insidious. Accumulated fatigue due to lack of attention to simple things like regular sleep habits, nutrition and fitness can gradually mount and imperceptibly affect performance. Not unlike practising physicians, medical students can have a remarkable ability to ignore features of illness and fatigue in themselves which they would very quickly recognize in others.
- Mental illness. Medical students, like all young people, could suffer from chronic mental illness or develop such conditions after entering medical school. These can be very difficult to recognize in oneself and there may be stigma associated with such conditions that inhibit affected individuals from recognizing their full significance or in seeking help.
The objective of any faculty advisor or mentor engaging the FTMSS sufferer, of course, is to help the afflicted student understand the problem and therefore engage effective therapies. The clinical approach for students exhibiting signs of FTTMS, ultimately, is not unlike that for other conditions that have behavioural manifestations. It begins with understanding and acceptance that the troublesome behaviour likely has an underlying precipitant that can be defined and therefore managed.
Diagnosis requires a thorough history focused on the potential causes listed above, and features that may help identify the underlying, culprit problem. Having identified a potential underlying mechanism, counseling is required to help the students themselves understand cause and effects. Together, management can be engaged.
What happens when none of the potential mechanisms seems to fit, and we come up with an idiopathic etiology? In my experience, this is very rare, but obviously troubling. Are we simply dealing with a poor “fit” for medicine? In such cases, we should provide compassionate support and oversight – what some clinical colleagues would term “watchful waiting”. Clarity usually emerges with time and, with it, the optimal approach becomes obvious to all.
And so, the process for assessing a medical education problem bears remarkable similarity to the process we teach and use for any clinical problem. Once again, there’s a striking parallel between patient care and medical education. Doctors instinctively engage their students as they do their patients. Without judgement, but rather thoughtful contemplation of how observed manifestations reveal underlying mechanistic causes, leading to understanding and, with it, effective intervention.
Evaluating the Student Experience: Assessing satisfaction is important, but not enough
“Universities are centres of learning, not teaching”
These were the words, uttered many years ago, by a former professor and teacher in response to some very demurely and deferentially expressed comments about the quality of lectures being provided in a particular medical school course. The message, directed to me and a couple of my classmates, was pretty clear. The university and faculty would provide opportunities to learn, in whatever manner they felt appropriate. It was not for us, as mere students and consumers, to question the methods. The responsibility for our education was ours.
In fact, in recent discussions with a number of my medical school contemporaries who I’m fortunate to meet with regularly, none of us could recall, during our four years of medical school, ever being asked for feedback of any kind about our educational program. If such processes existed, either internal or external to the school, they were largely invisible to the students of that time. This was certainly not unique to our school. For our generation, medical education was very much a “take it or leave it” proposition.
This is not to say we didn’t get excellent teaching, role modelling and mentorship. We certainly did, and many of us found our inspiration for education in those early experiences. It’s also almost certainly true that many of the teachers of that time quietly observed and responded to the impact of their methods on their learners. However, the culture of the day simply did not provide methods by which the student experience could be collected and analyzed.
This rather parochial approach was not exclusive to medical education. Patients of the past were rarely, if ever, surveyed for feedback about the quality of care they received from institutions or individual physicians. Corporations and businesses largely allowed the public to “vote with their feet”. If the product wasn’t good, people wouldn’t buy it, or would simply walk away.
Clearly, things have changed.
In the business world “Consumer Satisfaction” is an industry in itself. Successful businesses aggressively seek out customer feedback because they have learned that responding to real or even perceived needs drives future spending. IBM has taken this a step further. They go beyond the need to ask questions and, instead, are building and offering services that track consumer behaviour and provide that information to service and product providers. To quote from their site:
In health care, knowledge of the patient experience is now considered essential to a well- run institution. Hospitals are expected, through accrediting processes, to actively seek out patient perspectives
The Agency for Healthcare Research and Quality operates within the U.S. Department of Health and Human Services. Its mission is “to produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable”. To quote from their site:
“Understanding patient experience is a key step in moving toward patient-centered care. By looking at various aspects of patient experience, one can assess the extent to which patients are receiving care that is respectful of and responsive to individual patient preferences, needs and values. Evaluating patient experience along with other components such as effectiveness and safety of care is essential to providing a complete picture of health care quality.” (https://www.ahrq.gov/cahps/about-cahps/patient-experience/index.html)
They make an important distinction between patient satisfaction and the patient experience. Satisfaction is a subjective impression of a patient’s interaction with an institution or individual, and is largely based on whether their personal expectations were met. The patient experience relates to gathering information, available only through patient reporting, that is relevant to determining whether certain institutional goals are being achieved.
A person test driving a new automobile, for example, is able to report on both the driving experience (acceleration, braking, ease of handling, visibility etc…) and their personal satisfaction (enjoyment, comfort, excitement) driving the car. To those designing and building the car, evaluating the driving experience allows them to determine if the equipment and concepts they developed are working as expected. Evaluating driver satisfaction determines whether the consumer is getting what was expected from the car, which may be unclear to the designers. Both are relevant to success. Both are certainly relevant to the likelihood that the consumer will purchase the car.
In medical education, the value of student feedback is widely appreciated and schools go to considerable effort and expense to collect it. In fact, the systematic collection of feedback is mandated by accreditation standards, and the evidence required to establish compliance with those standards is based largely on student feedback. The distinction between measurements of the student experience and student satisfaction is relevant, both being important goals. Systematic Program Evaluation must encompass both.
At Queen’s, we recognize that many goals of our educational program can only be fully assessed with the perspective of those actually experiencing and living the process. We also recognize that a full picture only emerges if many points of feedback are provided. We have therefore put in place many and varied opportunities for students to provide both their personal perspectives and objective observations.
After each course, students are invited (and expected) to provide feedback that consists of responses to questions exploring pre-determined educational objectives, and provision for narrative commentary in which they can elaborate or explore other aspects. Those end-of-course evaluations also provide opportunity to provide similar feedback regarding the effectiveness of teaching faculty.
We receive and carefully review the results of course-related examinations undertaken by our students, not only to gauge their learning, but also the effectiveness of the teaching and learning opportunities provided.
We anticipate and review closely the results of external examinations undertaken by our students, such as the Medical Council of Canada Part 1 and 2 examinations, and all National Board of Medical Examiners tests we utilize. These provide valuable comparators to other institutions and, to a limited extent, further feedback about our teaching effectiveness.
The Canadian Graduation Questionnaire is completed annually by all graduating medical students and provides a comprehensive review of all aspects of their educational experience. We review it in great detail, and many aspects of the CGQ are incorporated into the accreditation process.
We have established a Program Evaluation Committee that, for the past few years has been under the leadership of Dr. John Drover. That group collects, collates and analyzes data from a variety of sources to provide an overarching analysis of our performance relative to our programmatic goals. The PEC recently released a comprehensive report, which has been passed along to the Curriculum Committee for analysis and action. I am very grateful to Dr. Drover who has generously and effectively provided PEC leadership. He is now passing that role along to Dr. Cherie Jones as she assumes her role as Assistant Dean, Academic Affairs and Programmatic Quality Assurance.
We have also developed a number of more informal ways by which students can provide feedback.
We meet regularly with student leadership and curricular leads to get “on the fly” feedback about courses as they are taught. This often causes us to undertake adjustments or provide supplemental content even before the course is completed.
We provide numerous ways in which students can report personal distress or incidences of mistreatment at any point during their medical school experience. These range from direct contact with selected faculty members, our external counselor (who can be contacted directly and is completely segregated from faculty or assessment) or submission of reports that can be embargoed until a mutually agreed to time. All these are outlined in our policies and accessible through convenient “Red Button” on MedTech.
I have found “Town Halls” to be very valuable sources of feedback on all aspects of the MD program. These are held at least once per term with each class and consist of a few “current events” items I provide, followed by “open mike” time when students are invited to bring forward any commentary or questions they may have, about any aspect of the program. The issues that emerge and dialogue among students in attendance can be highly revealing and have certainly provoked new directions and changes over the years.
Recognizing that not all students are comfortable with speaking out, or may not wish to be identified as they raise sensitive issues, a confidential portal was established on MedTech a number of years ago. Students are able to provide their commentary in a completely anonymous fashion if they wish. My commitment is to read and consider (but not necessarily act on) all commentary provided, and to respond personally if students choose to identify themselves. To date, I have received almost 500 such submissions, about 70% of which are provided anonymously. The commentary has been thoughtfully provided and has spanned all aspects of our program and learning environment. Importantly, it often brought to light issues that had not previously emerged in any other way.
In all these ways, student feedback has become a continuing, multi-faceted component of our school and, more broadly, our learning environment. It goes beyond being a mechanical, mandated exercise and data collection. It is embedded and cultural. It is what we do. It is who we are.
Residency Match Day 2019: What our students are experiencing, and how to help them get through it
If life were a roller coaster, our fourth year students have, for the past few months, been on quite a wild ride, slowly rumbling upward, gradually ascending to the summit, stopping for a moment as they stare downward to a distant, small landing point, readying themselves for a rapid and rather scary descent.
The process by which learners transition from undergraduate to postgraduate medical education has evolved into a rather jarring and extremely stressful experience (don’t get me started – a subject for another blog/rant). It has required them to not simply consider what specialties are best suited to their interests and skills, but engage an application process that requires strategic selection of elective experiences, preparation of voluminous documents, meeting multiple deadlines (twelve, no less), and commitment of personal time and expense to travel and interviewing which, for many, spans the country in the midst of the Canadian winter.
This year, the roller coaster reaches its summit at 12:00 noon on February 26th. The much anticipated Residency “Match Day” is when all fourth year medical students in Canada learn which postgraduate program they will be entering. By approximately 12:00:05 that day, all students will know their fate. As you can imagine, there will be much anticipation and anxiety leading up to the release. For most (hopefully all), the roller coaster ride will end with the exhilaration and satisfaction of having successfully overcome the process. For a few (and hopefully none), it will bring a realization that their efforts to date have not been successful, that their ride is not yet over, and they have to begin again. They will be profoundly disappointed, they will be afraid, they will be confused. They will need the understanding and help of the faculty who are currently supervising their training, and much help from our Student Affairs staff.
This year, we are again prepared to provide all necessary supports, but there are a few changes to the process which I’d like to clarify for both students and the faculty that will be supervising them that day:
- Unlike previous years, our Undergraduate Office will not automatically receive match results the day before the full release. However, students have the option of directing CaRMS to release their results the day before (February 25th) if they fail to match. They can do so by going into the CaRMS website and providing the appropriate permission.
- Any unmatched students who have
allowed early release will be contacted directly by myself to notify them of
the result. This is for three purposes:
- to arrange for immediate release from clinical duties
- to allow the student some time to prepare for the release moment the following day when most of their classmates will be hearing positive results
- to arrange for the student to meet our student counselors who will provide personal support and begin the process for re-application through the second iteration of the residency match.
- Unmatched students who did not opt to provide early release will similarly be contacted and offered the same support and services after we get their results on match day.
- Because we may not have full information in advance, we have decided to release all students from clinical obligations beginning noon on match day, until the following morning.
I’d also like to remind all faculty supervising our fourth year students on or around match day to anticipate that your student will be distracted. Please ensure your student is able to review the results at noon. If you sense he or she is disappointed with the result, please be advised that the student counselors and myself are standing by that day to help any student deal with the situation and provide support.
Fortunately, we have an outstanding Student Affairs team which has been working hard to guide the students through the career exploration and match process, and will be standing by to provide support for match day and beyond.
The team can be accessed through our Student Affairs office email@example.com, or 613-533-6000 x78451.
Thanks for your consideration, and please feel free to get in touch with myself or any of the Student Affairs Team if you have questions or concerns about Match Day or beyond.
A Brief History of Walls
Are walls effective? As we’re all aware, this seemingly innocent question has become a focus of considerable controversy for our neighbours to the south. Of course, it’s not about the sort of walls that separate rooms of your house, or the barriers around your property that deter trespassers and prevent your dog from molesting your neighbour’s flower bed. Rather it’s about massive barricades erected by political leaders to prevent or control the movement of large populations of people at borders. As it happens, there’s a rather interesting and intriguing history of such structures, both real and mythical.
Publius Aelius Hadrianus Augustus (76-132 AD) ruled when the Roman Empire was at its peak and is considered by many historians to be one of the “good emperors”. He seemed less interested in further expansion than in consolidation and security of his already vast empire. As part of that approach, he commissioned the building of a wall to define and secure the northernmost extent of the empire. Construction of Hadrian’s Wall began in AD 122. The wall is composed mostly of stone and is about 10 feet wide and up to 10 to 20 feet in height. The wall connects a series of fortifications located every 5 (Roman) miles. It runs about 73 miles, from the banks of the River Tyne near the North Sea in the east, to the Solway Firth on the Irish Sea to the west. It required a garrison of about 1,500 men and was intended to prevent the “barbarians” (ancient Britons and Picts) from troubling Roman Britain.
Hadrian’s successor, Antoninus Pius, seemed to like the concept but felt the boundary should be expanded and so, in 138 AD constructed a second wall about 100 miles to the north. The Antonine Wall was 40 miles in length. Despite the wall, Antoninus was unable to contain the northern tribes and so subsequent emperors abandoned his wall and re-occupied Hadrian’s Wall.
Today, Hadrian’s Wall is a tourist destination. It was declared a World Heritage Site in 1987, but remains unguarded. Tourists commonly climb and stand on the wall, although this is not encouraged for fear of damage to the historic structure.
The Walls of Troy
Troy was an ancient city located on the northwest coast of Turkey.
Archeological research of that site has revealed that it has been inhabited since about 3000 BC. Dutch researcher Gert Jan van Wijngaarden notes in a chapter of “Troy: City, Homer and Turkey” (University of Amsterdam, 2013) that there are at least ten settlements layered on top of each other.
It is not clear whether the ten year siege by Greeks led by King Agamemnon and described so famously in Homer’s Iliad is wholly or even partially true, but both the legend and the archeologic evidence indicate that the city was, at one time, surrounded by a rather impressive defensive wall. Van Wijngaarden notes that deep under the surface evidence exists of a“small city surrounded by a defensive wall of unworked stone.” In the period after 2550 B.C, the city “was considerably enlarged and furnished with a massive defensive wall made of cut blocks of stone and rectangular clay bricks”.
The legend, of course, indicates that the Trojans were able to hold out for ten years, but the wall was eventually overcome not by force but by clever deception: Ulysses famous “Trojan Horse”.
The Walls of Babylon
Babylon was a city and city-state located in Mesopotamia and a dominant presence in the world for over twelve centuries, ending about 600 BC. It was a key commercial and cultural centre and it is believed that, at various times, Babylon was the largest city in the world, and perhaps the first with a population exceeding 250,000.
A prominent feature of Babylon were its extensive walls. Various rulers would add successively to the work of their predecessors. Nebuchadrezzar II surpassed most by fortifying the existing double wall and actually adding a third. He also added a separate wall north of the city between the Euphrates and Tigris rivers. Considered to be over 100 feet high at points and extending 41 miles, both the sheer magnitude and artistic features of the walls were remarkable, notable particularly for the “hanging gardens”. They are considered one of the “Seven Wonders of the Ancient World”.
Extensive efforts have been made to excavate various components of the ancient city, which has been partially reconstructed as a historic and tourist site. Unfortunately, the reconstruction has been damaged by the development of oil pipelines and military conflicts. In April 2006, American Colonel John Coleman, former Chief of Staff for the 1st Marine Expeditionary Force, issued an apology for the damage done by military personnel under his command.
The Great Wall of China
Perhaps the most famous extant wall in the world was built to protect the then northern border of China from invasion by various nomadic tribes. The “Great Wall” was actually built in portions over several centuries beginning in the 7th century BC
and finally enlarged and united into a single structured with embedded towers and fortifications. The main construction of the existing wall dates to the Ming Dynasty (1368-1644).
In addition to its defensive purpose, the wall also had a border control function, controlling immigration and, serving as a tariff collection station for goods being transported along the “Silk Road” between eastern and western markets.
It extends 21,196 km making it clearly the most extensive wall ever constructed. Whether it is the only man-made structure visible from space is a point of contention. There has never actually been a recorded “sighting” from space, although a Chinese astronaut in the space station claims to have taken a photograph using high resolution equipment. What is clear is that it is a UNESCO World Heritage Site and a symbol of modern China. Although many portions of the wall are in disrepair and eroding, it remains an extremely popular tourist attraction, arguably, the world’s most sought-after selfie opportunity.
The Berlin Wall
A more contemporary example is the Berlin wall that physically divided that city between 1961 and 1989. Its history is both fascinating and instructive.
After World War II, the Potsdam Agreement determined that the victorious allies would divide Germany into four zones of occupation controlled by the United States, the United Kingdom, France and the Soviet Union. The German capital, Berlin, was the centre of administrative control of all four powers and so was similarly divided into four sectors. However, Berlin was entirely within the Soviet controlled portion of former Germany. Within a short period of time, political tensions mounted between the Soviets and the other three nations, largely related to the Soviets’ reluctance to agree to the Marshall Plan which called for the reconstruction, self-governance and economic support of post-war Germany. The United States, United Kingdom and France decided to proceed nonetheless, uniting their portions into a single country which came to be called West Germany (officially, the Federal Republic of Germany), with a capital located in Bonn. East Germany (known as the German Democratic Republic) emerged as a separate and Soviet controlled state, with its capital in Berlin. This left Berlin under divided governance but entirely within a separate and rather unfriendly state.
East Germans began to use West Berlin as a means to defect to western countries. It is estimated that 3.5 million circumvented emigration regulations by simply crossing into West Berlin and then on to West Germany and other countries. To prevent this exodus, the GDR (East German) leadership constructed a concrete, militarized wall essentially separating and isolating West Berlin within East Germany. During the time it was in place, over 100,000 people attempted to escape and about 5,000 succeeded in doing so. They were taking serious risks. According to the Centre for Contemporary History, a research institute concentrating on recent European history, at least 140 people are known to have been killed attempting to cross the wall, ranging from a one-year old child to 80-year old woman. Most believe the number to be considerably higher.
Eventually bowing to anti-communist sentiments in neighbouring countries and civil unrest, the East German government lifted restrictions on movement within Berlin in November of 1989, which led to open and euphoric celebration. People began chipping away parts of the wall until the government removed what was left of it. Germany officially became re-unified October 3, 1990.
Today, only small segments of the wall remain, including “Checkpoint Charlie”, its best known militarized crossing point. The Berlin wall is seen as a failed attempt by a government to impose its will on its citizens. Because it is so recent in our collective memory and so well documented, it has become a powerful image of oppression and courageous defiance. It too has become a popular tourist destination.
“The Wall” (Game of Thrones version)
The most famous albeit imaginary wall of our time no doubt comes from “Game of Thrones”, a hugely popular HBO series based on the fantasy novels of George R.R. Martin. A key feature is “The Wall”, a massive fortified structure composed of solid ice stretching across the northern border of the “Seven Kingdoms”. It is intended to provide protection from the various miscreants beyond, including “Wildlings” and a wandering army of frozen zombies referred to as the “White Walkers”.
Seemingly inspired by Hadrian’s Wall, this frozen barricade stretches from coast to coast, has fortifications along the way, and is manned by a garrison of exiled misfits referred to as the “Night’s Watch”. Apparently, Wildlings and White Walkers don’t swim or paddle. In any case, the wall has held up for millennia but, guess what happened at the end of last season?
(SPOILER ALERT: stop reading if you’re catching up on the series).
It comes down!!!….courtesy of a resuscitated and demonically-possessed fire-breathing dragon, no less! We’ll have to wait until next season to see if it becomes a tourist attraction.
And so, what does all this teach us about massive walls (real or imaginary) intended to separate populations of people? What themes and lessons emerge?
- They don’t work. People (even zombies) are smarter than walls, and are very capable of finding ways to overcome them. This is particularly true of people who are seeking better lives for themselves or families. Walls are static structures that can be overcome by imagination, determination and technology.
- Walls are hugely symbolic. They serve as a very visible expression of the values and priorities of those who construct them. The fences around our homes may not actually prevent a determined person from entering our property, but they certainly clarify for all the world that uninvited folks are unwelcome.
- They endure over time as artefacts, searched out and studied by historians and archeologists. They express and expose for posterity the true, unvarnished values and motives of those who constructed them. This persists long after they stop providing their original, intended purpose.
- They seem to serve as ideal, although expensive, tourist attractions.
If the planned wall does get built, can’t help but wonder how future generations will interpret the existence of a massive barricade on the southern border of a nation that also erected this other symbol at its major eastern port, proudly declaring to the world, “Give me your tired, your poor, your huddled masses yearning to breathe free.”
Service Before Self: The Legacy of George H.W. Bush
I’ve always liked George Herbert Walker Bush.
I realize, as I write those words, that it’s somewhat inappropriate and maybe even a little pretentious to use the term “liked” in reference to a former President of the United States who I never met or knew personally. It implies a familiarity I certainly can’t claim. Words like “respected” or “admired” might be more suitable, and are certainly applicable. But, in truth, “liked” is what comes immediately to mind. So, why is that? I think it’s because what has resonated with me as I’ve watched and read the various tributes since his passing a couple of weeks ago, and what probably resonates with most Canadians, are the fundamental human qualities- honesty and vulnerability-he maintained through his life. A few quotations provide insight into the character of the man.
In describing his neurologic symptoms that confined him to a wheelchair during his later years:
“It just affects the legs. It’s not painful. You tell your legs to move and they don’t move. It’s strange, but if you have some bad-sounding disease, this is a good one to get.”
While he was president, he famously indulged a life-long food preference by banning broccoli on Air Force One:
“I do not like broccoli. I’m president of the United States, and I’m not going to eat any more broccoli.”
In ending a contentious discussion with his Secretary of State James Baker:
“If you’re so smart, Baker, why am I president and you’re not?”
How can you not like someone so genuine?
Despite being what we might term a person of privilege, he seemed and acted like a regular, decent, fair and unfailingly respectful person caught up in powerful roles and great events. In terms of attitude and character he was, one might respectfully conjecture, an American that many Canadians can identify with and feel a certain kinship.
But none of that should detract from what he did or accomplished through his life. He was, arguably, the most qualified and best prepared person ever to assume the presidency, having previously served his country as a World War II combat pilot, two terms in congress, Ambassador to the United Nations, Special Envoy to China, Director of the CIA and two terms as Vice-President.
He advanced environmental concerns and worked to reduce trade barriers in North America. He led the US at a time when it was the only significant superpower in the world and could therefore have exerted unilateral authority. But he chose not to. Instead, he responded to the Iraqi invasion of Kuwait by firstly seeking the advice of the Canadian Prime Minister of the time, Brian Mulroney, and then working through the United Nations to form a multi-national coalition to engage the threat. When the former Soviet Union collapsed, he cautioned against gloating and maintained a respectful attitude. In a recent statement current Russian President Vladimir Putin provided the following tribute:
“George Bush Sr. was well aware of the importance of a constructive dialogue between the two major nuclear powers and took great efforts to strengthen Russian-American relations and cooperation in international security,”
He never wrote an autobiography, but wrote thousands of personal letters, casually composed but highly articulate and poignant, cherished by those who received them.
What is perhaps most remarkable about him is that, despite being what we might consider a “person of privilege” who could easily have chosen a life of quiet and private comfort, he made deliberate choices to engage public service, beginning with his decision to drop out of school and voluntarily enlist in the Navy at the age of 18 against family advice. He became a naval aviator undertaking 58 combat missions, during one of which he was shot down and had to be rescued at sea. That would have been enough for most people. Returning home after the war, he could easily and understandably have entered a comfortable private life as a successful businessman, but instead chose public service leading to the numerous positions and culminating in the presidency in 1988.
His family members, who have themselves taken up positions of social and political responsibility, remember his exhortation of “Service before Self”.
Perhaps the most revealing GHW Bush quotation are the words of a note he left in the Oval Office for his successor, Bill Clinton, who defeated him in the 1992 presidential election:
The last five sentences are perhaps the most telling of all and speak volumes about the author
You will be our President when you read this note. I wish you well. I wish your family well. Your success is now our country’s success. I am rooting hard for you.
Truly a life of Service before Self. A legacy and example for his nation. Indeed, for us all.
The Essential Elements of Medical Education Transcend Politics and Culture
How do you judge a medical school? Specifically, how do you know if it’s providing an effective educational experience for its students? There’s no shortage of perspectives on that question. Everyone involved in medical education, from first year students to Deans, will happily weigh in. Theories and opinions abound, ranging from the rigorous application of systematic Program Evaluation involving the collection, processing and consideration of multiple pre-determined sources of data, to the “I know it when I see it” approach. Our accrediting agencies certainly favour a data driven approach, now requiring the analysis of twelve standards which break down to 95 elements requiring the collection and reporting of literally hundreds of individual points of information.
I was recently faced with this question, with the added complexity that the medical school was situated in a country with very different political and social structures than our own, and very different challenges to the delivery of health care. The school was in a large (very large) city in China, and I was part of a small team asked to provide perspectives on a recently developed English language program.
The obvious and perhaps easiest approach is to measure it against our established, North American accreditation standards. However, I found many of the standards, particularly those relating to issues such as diversity, admission procedures, faculty appointments and governance, simply did not translate to that cultural context. So, I decided to concentrate instead on the essentials – those elements that are foundational to any medical education process and should retain relevance regardless of social or political context. With that in mind, I concentrated on four “essential ingredients” of medical education.
The first, and most obvious, is students. Medical education is fundamentally about student learning and their personal development as physicians. They therefore need to be capable of learning and, probably more importantly, motivated by a true commitment of service to their future patients and communities. The students I encountered certainly had those attributes. They were very well-qualified academically, highly-motivated, ambitious and adaptable. They also seemed to have high levels of social responsibility and commitment to utilizing their medical training in the interests of their society. They are also all only children which, I came to learn, puts them under considerable pressure to succeed.
Students need to encounter teaching faculty, basic scientists and clinicians committed to the process of passing along their accumulated knowledge, experience and wisdom to the next generation of physicians. Their commitment must be based not simply on conditions of employment or obligations, but an almost instinctive impulse to teach that they see as part of their professional role and personal mission.
In China, I met numerous clinical faculty and curricular leaders during the visit who were uniformly committed to providing education both through formal teaching and in conjunction with their clinical responsibilities. They saw this as an embedded component of their appointments, and felt supported in their roles through provision of faculty development. When pressed, they admit that educational responsibilities are provided “over and above” their clinical or academic roles.
Together, students and teachers must encounter patients. Those patients must be accessible, representative of the conditions and circumstances students will eventually encounter, and be willing to participate in the educational process. In the Chinese school I reviewed, there was virtually unlimited and unfettered access to patients of all types. This is the result of the sheer volume of patients and pathology in a city whose population approaches that of all Canada. Whereas many Canadian schools struggle to ensure students are exposed to all clinical problems, clinical instructors in China are able to select patients for students to see and work with based on their educational needs. The Internal Medicine clerkship director pointed out how she is able to first identify what clinical problems any particular student needs to encounter, then select among multiple appropriate patients.
The fourth essential element is resources. These include space for teaching, facilities for basic science instruction and the equipment and technology necessary to provide contemporary medical care. This requires a commitment on the part of school and medical leadership to ensure resource stewardship, and mechanisms to ensure they have the means to ensure updating and refreshing into the future.
And so, in the end, the similarities were much more significant than the differences. It comes down to students, teachers and patients coming together in an environment providing adequate resources to allow the educational process to flourish. When they do, it seems education just happens, almost spontaneously. Without any of the first three fully in place, it’s not possible, even with outstanding resources.
The purpose of a medical school and its leadership is to ensure the essential elements are in place and well-supported. Once they are, education happens. The urge to learn and to teach, it would seem, transcend geography, culture and politics.
Engaging Disruptive Innovation. The evolving role of POCUS in clinical medicine and medical education.
Who among us didn’t get through high school without regularly reaching for a well-thumbed encyclopedia plucked from a shelf in our parents’ basement or local library reference room? Not me, to be sure. Whether it was how rubber is manufactured, legislative accomplishments of a long-deceased prime minister, or the agricultural exports of Guatemala, the encyclopedia could always be counted on to provide reliable information, in time for whatever deadline was looming.
The word “encyclopedia” itself has an interesting and revealing etymology. It apparently contains elements of word origins for “circle” (interpreted to mean “complete” or “all-inclusive”), “child” and “education”. We all know the word to refer to a comprehensive, single source that brings together diverse information. An encyclopedia is a one-stop-shop for a little bit of everything you might need to know about anything.
The most venerable example is Encyclopædia Britannica, first published in 1768 (https://www.britannica.com/topic/Encyclopaedia-Britannica-English-language-reference-work). The 2010 edition consisted of 32 volumes and 32,640 pages. It was written by about 100 full-time editors and more than 4,000 contributors. Contributors have included Nobel laureates and five American presidents.
That 2010 edition version was its last print edition. After 242 continuous years, Encyclopedia Britannica went out of the print business. It was a victim of what has come to be known as Disruptive Innovation.
That concept emerged in the 1990s and is most commonly attributed to Clayton M. Christensen who has written extensively on the topic as it plays out in the business world and explains the rise and failure of various enterprises.
In a 1995 Harvard Business Review article that is well worth the read (https://hbr.org/1995/01/disruptive-technologies-catching-the-wave), Christensen defines disruptive technologies in the following way:
The technological changes that damage established companies are usually not radically new or difficult from a technological point of view. They do, however, have two important characteristics: First, they typically present a different package of performance attributes—ones that, at least at the outset, are not valued by existing customers. Second, the performance attributes that existing customers do value improve at such a rapid rate that the new technology can later invade those established markets. Only at this point will mainstream customers want the technology. Unfortunately for the established suppliers, by then it is often too late: the pioneers of the new technology dominate the market.
The disruptive innovation that lead to the demise of print versions of Encyclopedia Britannica was, of course, Wikipedia. It provided an easily accessible, comprehensive and continually updated source of information at no direct cost to the consumer. The fact that it lacked historical status, cachet or even a reputation for the accuracy of its sources was glossed over by the consuming public who were very willing to set aside all those considerations for the convenience and economic advantages.
Disruptive Innovation, almost by definition, upsets existing patterns of practice or behaviour and resets the way people go about a common task or access a service. There is always a reaction from those involved in the traditional paradigm, usually characterized by statements such as
“what’s the proof this is better”
“there’s no problem with what we’re doing now”
“it hasn’t been fully researched”
“there will be unintended consequences”
The disruptive innovators, for their part, have the courage of their convictions. They believe they understand market forces better than the established providers, and are willing to gamble that they’re right. Basically, they believe in letting the market decide.
The medical world, of course, is certainly not excluded from disruptive innovations. In fact, it has benefited greatly, but not always willingly. An example I’m very familiar with from the cardiology world is Percutaneous Coronary Angioplasty. When first introduced by Dr. Andreas Gruentzig in 1977, this innovation truly set the cardiovascular world on its collective ear. Prior to that, therapies for coronary occlusive disease were limited to medical therapies (provided by cardiologists) and coronary bypass surgery (provided by cardiac surgeons). The dichotomy and division of labour were clear and well accepted. The catheterization laboratory was a place for diagnostic investigations to determine the extent of disease, not a place for therapeutics. Gruentzig’s innovation completely upset the existing paradigm. Moreover, it put the interventional cardiologists in the driver’s seat, because they could link the therapeutic intervention to the diagnostic procedure, therefore engaging the issue first and therefore, potentially, circumventing the role of the cardiac surgeon. The simple intuitive appeal of being able to dilate an obviously obstructed vessel without the need for even a second interventional procedure, much less surgery, was powerfully compelling, and both the medical community and patients were very willing to set aside the usual and well-established need for controlled comparative trials before embracing this new technology enthusiastically.
The development of Hand-Held Ultrasound (HHU) and its clinical counterpart, Point of Care Ultrasound (POCUS), could be considered further disruptive innovations facing the medical community. Ultrasonic imaging, by virtue of its ability to provide information on a variety of structures in a non-invasive, non-toxic manner and at relatively low cost, has taken on a key role in medical diagnostics, ranging from cardiac (where it is known as Echocardiography) to abdominal, thoracic and vascular imaging. It was initially provided only with large and complex machines that were not easily transported, and provided images and measurements which were imprecise, difficult to obtain and required “expert” recording and interpretation. The technology therefore required third party interpretation and consultation before results could be reliably utilized to guide patient care.
Over the past decade or so progressive technical advances have made it possible to obtain excellent quality images from small devices that can be carried easily and used at the bedside. This technology is such that it can be used by an individual to guide the diagnostic approach and decision-making process, analogous to how physicians use stethoscopes. Although the HHU technology is not yet able to provide the full package of information that would allow it to completely replicate the comprehensive examination, it’s not unreasonable to expect that will occur in the not-too-distant future.
In addition to challenging the role of ultrasonic imaging as a diagnostic procedure, this technology is also challenging our approach to the clinical examination in medical school, where students and educators are asking very valid questions as to the role of these “competing” technologies.
I recently participated in a symposium at the Canadian Cardiovasular Congress recently exploring this very topic. Together with my colleague Dr. Amer Johri, as well as Dr. Sharon Mulvagh from Dalhousie, Dr. Rob Arntfield from Western University, and our former Echocardiography Fellow (now staff Cardiologist at McGill) Dr. Hanane Benbarkat, we explored current and further applications of HHU and POCUS, all centred on its fundamental impact on patient care.
Dr. Johri has been active in the development of guidelines for its application in medical education (Journal of the American Society of Echocardiography 2018;31:749), and has been working with Dr. Steven Pang of our department of Biomedical and Molecular Science to introduce the technology within our curriculum.
The session was, as you might imagine, not without controversy. However, I believe the discussion ultimately centred on the only truly relevant issue: how we can utilize emerging technology to better serve the needs of patients. The concluding messages I provided our audience at that symposium are:
- HHU and POCUS are excellent examples of disruptive innovation
- They challenge our conventional approaches, but have considerable potential to bring added value to both the clinical setting and educational process
- They are here to stay – but how, and who will be guiding their use is not yet determined
- They have the potential to evolve from disruptive to sustaining innovations
- The key consideration in assessing value should be the impact on patient care
- Based on work carried out by Dr. Benbarkat during her fellowship at KHSC and hopefully extended to further collaborative studies with other centres, integrated utilization of POCUS by hospital-based Echo Labs is feasible and beneficial.
I’ll conclude with the words of Mr. Christensen who has given much thought to what causes organizations to fail in the face of disruptive innovation. In his book “The Innovator’s Dilemma” he provides a rather disturbing paradox:
“in the case of well managed firms…good management was the most powerful reason they failed to stay atop their industries.”
“widely accepted principles of good management are, in fact, only situationally appropriate.”
In other words, it was, at least in part, a failure to deviate from previously successful practices that prevented well-established firms from engaging disruptive innovations, ultimately to their detriment. Such innovations challenge us to step away from what we consider to be the “tried and true” methods and approaches we have come to rely upon. They will always entail an element of risk and uncertainty, and therefore require what might be termed a leap of faith. In the medical world, that leap is only justified by a considered, clear potential to improve patient outcome. All other considerations must take a back seat.
Well trained and committed clinicians can indeed succeed in the research world. Celebrating the accomplishments of two Queen’s Grads
Most organizations we join in the course of our professional careers are a natural consequence or requirement of what we do. There are others that carry some degree of prestige or special recognition that we may choose to apply to with the hope of being selected. A few organizations – very few indeed – come looking for special people. These are called “Honorific” societies, because they seek and recognize individuals whose lifetime work merits special recognition.
The Royal Society of Canada is such an organization. According to its website:
The RSC is the recognized pre-eminent body of independent scholars, researchers and creative people in Canada whose Fellows comprise a collegium that can provide intellectual leadership for the betterment of Canada and the world.
RSC Fellows are men and women from all branches of learning who have made remarkable contributions in the arts, the humanities and the sciences, as well as in Canadian public life.
In the United States, the National Academy of Medicine is another such organization. It describes it’s goals as follows:
- An independent, evidence-based scientific advisor. To carry out our work, we harness the talents and expertise of accomplished, thoughtful volunteers and undertake meticulous processes to avoid and balance bias. Our foundational goal is to be the most reliable source for credible scientific and policy advice on matters concerning human health.
- A national academy with global scope. Although the National Academies were originally created to advise the U.S. government and advance the well-being of the U.S. population, our mandate is now much broader. The NAM includes members from across the globe and partners with organizations worldwide to address challenges that affect us all.
- Committed to catalyzing action and achieving impact. We identify and generate momentum around critical issues in health; marshal diverse expertise to build evidence-based solutions; inspire action through collaboration and public engagement; and foster the next generation of leaders and innovators.
- Collaborative and interdisciplinary. In partnership with the National Academy of Sciences, the National Academy of Engineering, and other stakeholders, the NAM draws on expertise across disciplines and domains to advance science, medicine, technology, and health.
- An honorific society for exceptional leaders. The NAM has more than 2,000 members elected by their peers in recognition of outstanding achievement. Through a commitment to volunteer service, NAM members help guide the work and advance the mission of the NAM and the National Academies.
Recently, two graduates of our medical school have been named to these societies. Dr. Stephen Archer is a friend and classmate from Meds 81. I’ll again quote from the citation provided by the RSC in announcing his appointment:
Stephen Archer is Professor and Head of Medicine at Queen’s University and a world renowned cardiologist and leader in several research fields, including oxygen sensing, vascular biology, and the experimental therapeutics of pulmonary hypertension and, more recently, cancer. He has made numerous discoveries that can undisputedly be considered firsts, particularly in regard to defining the roles of mitochondrial fission/fusion and metabolism in oxygen-sensing and cell proliferation.
Dr. Azad Bonni is a Meds 86 grad and well-remembered by many current faculty. He also has the distinction of being the younger brother of my colleague Dr. Hoshiar Abdollah. Again, I quote from a announcement provided by his current school:
Bonni is the Edison Professor and head of the Department of Neuorsciences at Washington University School of Medicine and director of the university’s McDonnell Center for Cellular and Molecular Neurobiology. An international leader in molecular neuroscience, Bonni has made seminal contributions to our understanding of how the brain is built at the level of individual connections between nerve cells, and how deregulation of those mechanisms contributes to neurological diseases. His group has discovered fundamental signaling networks within nerve cells that program neural circuit assembly and function in the developing brain. Using brain development as a guide, the Bonni laboratory also has provided novel insights into neurological disorders including neurodevelopmental disorders of cognition such as intellectual disability and autism spectrum disorders, brain tumors and neurodegenerative diseases.
Neither Archer nor Bonni acquired their research expertise while in medical school. However, I believe both would agree that their ability to formulate important and relevant research themes and the commitment required to pursue those issues in a scientifically rigourous fashion was rooted in their understanding and personal involvement in clinical medicine and likely fostered by exposure to people and situations they encountered as medical students.
The role of research in undergraduate medical education has always been controversial. In an increasingly packed undergraduate curriculum, it is often sacrificed in favour of the many therapeutic applications and competency objectives medical schools are expected to provide. In fact, many current curricular frameworks have chosen to exclude it completely.
At Queen’s, we made the deliberate decision to include it in our list of essential EPAs, our only departure and addition to the nationally accepted list. We include research involvement as a core component of our curriculum (the Critical Enquiry), provide opportunities for summer research involvement, and integrate aspects of translational research into our teaching in various courses.
We do so not with the expectation that every student will become an independent researcher, but because we believe understanding research methodology makes us all better “consumers” of new information and that these early experiences may be formative and awaken a passion for research in those who had not previously imagined it either within their reach or as component of their career.
Congratulations to Drs. Archer and Bonni, and thanks for affirming that solidly trained and committed clinicians can, indeed, achieve great things in the research world.
Adjusting to Medical School
Adjusting to a new environment never comes easily. Our bodies will eventually adapt to seasonal climate changes, travelling to different time zones, or high altitude, but it invariably takes some time, and involves a little discomfort along the way. Adjustments of any kind are easier if anticipated and understood in advance.
Medical school is an adjustment and, unfortunately, not always anticipated by those “taking the plunge”.
What’s the most difficult adjustment for first year medical students?
Asked that question, most would point to issues such as workload, engaging initial patient encounters, or perhaps aspects of technical competence involving physical examination or procedures. All important, to be sure, but these challenges are understood in advance, anticipated by our curriculum, and well within the abilities of the young people entering medicine, who are already very accomplished and have engaged the process and been selected with all these issues firmly in mind.
Beyond these anticipated challenges, there are other adjustments that are even more critical to success but much less well-appreciated or even unanticipated by students.
Why do we undertake educational programs? For many undergraduate university students, it is to either to pursue an area of personal interest, or to achieve prerequisites or qualification for a subsequent program. That’s certainly the case for students contemplating entry to medical school. These are certainly worthy goals, but they are personal and intended to promote individual objectives. In a professional program such as medicine, the goals of learning shift to encompass the interests of other parties, specifically future patients. The approach and motivation for learning must also shift. In the words of an astute former mentor “Medicine is a service industry”. Medical school is about preparing young people to provide that service. The learning is facilitated by that goal. In fact, it can’t occur without it.
Students entering medical school have achieved much recognition for their academic and personal accomplishments, the most recent and notable being their success in the admission process. As they undertake their studies together with equally accomplished classmates and in a system that defines success simply as “pass” with very little numerical grading, external kudos and other tangible evidence of success become increasingly rare. The perception of success must therefore shift from the external to internal as will, eventually, the responsibility for ensuring they remain knowledgeable and technically competent.
The expectation of professional behaviour
Medical education is patient-centred. Students learn early that their interactions with patients must be carried out with high standards of confidentiality, respect and personal behaviour. Although that expectation is easily understood within the patient contact itself, it is perhaps less immediately understood that the same expectations are in play with all their interpersonal and social interactions. The lines between their personal and student lives therefore become blurred. For most, this is a novel experience, and perhaps the first realization of what it means to have engaged a professional role.
Dealing with uncertainty
Students, particularly those from backgrounds in the physical or biologic sciences, have come to expect precision and certainty in their studies. The concept of “right” and “wrong” provides reassuring clarity and promotes the expectation that learning is a finite endeavor, culminating with the discovery of that single, correct response. In the study of medicine, they find a much less dichotomous world where many clinical issues are nuanced and require interpretation based on many variables. They must develop “approaches” based on “best evidence” always contextualized to the “patient’s unique circumstances”. For those accustomed to singular solutions, this can be quite unsettling.
All this can sound quite daunting but, like any life adjustment, will be eased with patience and support. Fortunately, much support is available. The quick “bonding” with classmates allows for the comforting realization that these challenges are not unique or some critical personal shortcoming, but rather ubiquitous features of the early medical school experience. Interactions with upper class colleagues, both planned and informal, provide further validation. Our Student Affairs programs, mentor groups, observerships and Clinical Skills groups all provide opportunities to discuss transition difficulties.
In the end, the adjustment is not merely about engaging a new educational program, but rather a more clearly defined identity and perspective of one’s role in the world.